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Pre and Post Operative
Physiotherapy Management In
Tendon Transfer of Hand
By Dr. Rajal Sukhiyaji
(M.PT. in Sports Science)
Contents
• Definition
• Principles of tendon transfer
• Prerequisites for tendon transfer
• Treatment goals
• Indications,...
Definition :-
• Tendon transfer is a surgical procedure that
involves moving the insertion of a tendon muscle
unit from on...
General Principles Of Tendon Transfer
Three important principles should be emphasized
1) The transfer should not significa...
Fundamental principles of muscle-
tendon units include the following:
1) Correction of contracture
2) Adequate strength
3)...
Prerequisites for tendon transfer
• The patient must be a suitable candidate.
• All joints must be fully passively mobile....
Treatment Goals
 Preoperative goals
A) Achieving and maintaining full PROM and AROM if
possible.
B) Achieving maximum str...
D. Complete comprehensive evaluation, including sensory
testing, functional assessments, ROM measurements,
strength testin...
Postoperative goals
A.Protect transferred tendon.
B. Maintain ROM of uninvolved joints and involved joints.
C. Control po...
Indications
• Poliomyelitis
• Paralysis of muscle
• Nerve injury (peripheral or brachial plexus)
• Injured (ruptured or av...
• Prompt consideration of tendon transfers is indicated if,
(a) The prognosis for neurologic recovery is poor even with
ne...
Contraindications
1. Contracture of joints or skin that would limit movement.
2. Lack of a suitable muscle or muscles for ...
Precaution
A. Acceptance of less than full PROM before transfer.
B. Overestimation of donor muscle strength
C. “Drag” alon...
Radial Nerve Palsy
• The classic ‘wrist drop’ result.
• When the wrist cannot be stabilized in extension, the power
of the...
Purpose
• It is impossible for the patient with this condition to
open the hand to grasp objects; therefore, the transfer...
Preoperative requirements
1. The wrist must be passively mobile in extension.
2. The MCP joints must be passively mobile i...
Tendon transfer for radial nerve palsy
1)Flexor carpi radialis transfer
• PT to ECRB for wrist extension
• Flexor carpi ra...
2)Flexor carpi ulnaris transfer
• PT to ECRB for wrist extension
• FCU to EDC for finger MP extension
• PL to rerouted EPL...
Flexor carpi ulnaris (FCU) transfer for radial nerve
palsy using pronator teres (PT), FCU and palmaris
longus (PL) as moto...
Post operative Management
Splint position
1. Elbow in 90 degrees of flexion.
2. Forearm in about 30 to 90 degrees of
pron...
• Week 0 to week 3 or 4: Splint/cast.
A. Maintain ROM of uninvolved joints
B. Protective ROM of individual joints
C. Avoid...
• Weeks 5 to 6: Muscle reeducation.
• Week 7: Begin dynamic flexion splinting if extrinsic
extensor tendon tightness is pr...
Different splints
Ulnar Nerve Palsy
• Affect pinch and grip strength and manipulation and
cause difficulty with the approach of objects due ...
• The signs indicative of ulnar nerve palsy are as
follows:
• Froment’s sign:
• Jeanne’s sign:
• Duchenne’s sign:
• Wartenburg’s sign:
• Purpose
▫ Restore balance and function of a hand
▫ This may occur as a result of prolonged compression
as in cubital tun...
• Preoperative requirements for ulnar
nerve lesion
1. The PIP joints must be fully mobile in passive extension
and the MCP...
Tendon Transfer for Ulnar nerve palsy
o Suitable muscle-tendon units include:
• Flexor digitorum superficialis, extensor ...
• Superficialis transfers are designed to integrate MCP
joint and IP joint motion. They do not, result in
increased grip s...
• Low Ulnar Nerve Injury
A) Intrinsic Rebalancing
1) FDS of middle finger (MF)
2) Zancolli lasso procedure
3) Brand transfer of ECRL/ECRB to intrinsics with
tendon graft
B) Restoration of power pinch
1...
Post operative management
• Splint position
1. Wrist in 45 degrees of extension.
2. MCP joints in 70 degrees of flexion.
3...
Postoperative day 10 to 14:
• Remove postoperative cast, have tension checked by
surgeon, and immobilize patient in splin...
Week 6:
• When the hand is removed from the splint and placed on
the table, there will be a slight relaxation of the posi...
• The patient should perform this exercise on a 1 to 2
hourly basis with 5 to 10 repetitions during the 1st week
of active...
Week 6 to 12:
• Progressive resistive exercises. It is important not to fatigue
the transfer.
• Light gripping activities...
Different splints
Median nerve Palsy
• Functional impairment from a median nerve lesion is
primarily the result of lost skin sensibility on ...
Purpose
• Restore balance and function of a hand.
• This may occur through prolonged compression as in
carpal tunnel synd...
• Preoperative Requirements prior to
opponensplasty for low level lesion (wrist)
1. Normal or maximal thumb web span.
2. M...
Tendon transfer for Median nerve
Low Median nerve palsy
• Opponensplasty :-
A. FDS of ring finger (RF) or
PL to APB : long...
B. Extensor indicis proprius (EIP) to APB: long opponens
splint
C. Abductor digiti minimi (ADM) to APB : hand-based or
long opponens
Post operative Management
• Splint position
• The wrist is immobilized in neutral
extension with the thumb held in full
op...
Postoperative day 10 to 14:
Remove postoperative cast, have tension checked by
surgeon, and immobilize patient in splint....
Week 6: Discharge splint for protection and begin
unrestricted AROM/PROM. May introduce light resistance.
Week 8: Progre...
High Median Nerve Injury
• Flexor Pollicis Longus
• Brachioradialis/FDS to FPL: dorsal blocking splint (possibly
long arm ...
Postoperative day 10 to 14:
Week 3: AROM of MCP/IP within splint to activate
transfer, six to eight times per day9
Week...
Different splint
Post operative Complication
• Scarring of tendon to surrounding structures
• Difficulty activating transfer.
• Transfer to...
Evaluation Timeline
Postoperative day 10 to 14 (after tension has been
checked by surgeon)
A. Control of edema and pain, ...
 Week 4: AROM of all joints with splint removed;
nonresistive activities in therapy, NMES for transfer
activation
Weeks ...
Recent advances
• Flexor digitorum superficialis opposition tendon transfer
improves hand function in children with Charco...
References
• Burke, Higgins, McClinton, Saunders, Valdata. Hand
and Upper Extremity Rehabilitation, A Practical Guide,
3rd...
• Cynthia Cooper, Fundamentals of hand therapy, Clinical
Reasoning and Treatment Guidelines for common
diagnosis of Upper ...
• Flexor digitorum superficialis opposition tendon transfer
improves hand function in children with Charcot-Marie-
Tooth d...
THANK YOU
Pre and post operative management in tendon transfer
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Pre and post operative management in tendon transfer Slide 1 Pre and post operative management in tendon transfer Slide 2 Pre and post operative management in tendon transfer Slide 3 Pre and post operative management in tendon transfer Slide 4 Pre and post operative management in tendon transfer Slide 5 Pre and post operative management in tendon transfer Slide 6 Pre and post operative management in tendon transfer Slide 7 Pre and post operative management in tendon transfer Slide 8 Pre and post operative management in tendon transfer Slide 9 Pre and post operative management in tendon transfer Slide 10 Pre and post operative management in tendon transfer Slide 11 Pre and post operative management in tendon transfer Slide 12 Pre and post operative management in tendon transfer Slide 13 Pre and post operative management in tendon transfer Slide 14 Pre and post operative management in tendon transfer Slide 15 Pre and post operative management in tendon transfer Slide 16 Pre and post operative management in tendon transfer Slide 17 Pre and post operative management in tendon transfer Slide 18 Pre and post operative management in tendon transfer Slide 19 Pre and post operative management in tendon transfer Slide 20 Pre and post operative management in tendon transfer Slide 21 Pre and post operative management in tendon transfer Slide 22 Pre and post operative management in tendon transfer Slide 23 Pre and post operative management in tendon transfer Slide 24 Pre and post operative management in tendon transfer Slide 25 Pre and post operative management in tendon transfer Slide 26 Pre and post operative management in tendon transfer Slide 27 Pre and post operative management in tendon transfer Slide 28 Pre and post operative management in tendon transfer Slide 29 Pre and post operative management in tendon transfer Slide 30 Pre and post operative management in tendon transfer Slide 31 Pre and post operative management in tendon transfer Slide 32 Pre and post operative management in tendon transfer Slide 33 Pre and post operative management in tendon transfer Slide 34 Pre and post operative management in tendon transfer Slide 35 Pre and post operative management in tendon transfer Slide 36 Pre and post operative management in tendon transfer Slide 37 Pre and post operative management in tendon transfer Slide 38 Pre and post operative management in tendon transfer Slide 39 Pre and post operative management in tendon transfer Slide 40 Pre and post operative management in tendon transfer Slide 41 Pre and post operative management in tendon transfer Slide 42 Pre and post operative management in tendon transfer Slide 43 Pre and post operative management in tendon transfer Slide 44 Pre and post operative management in tendon transfer Slide 45 Pre and post operative management in tendon transfer Slide 46 Pre and post operative management in tendon transfer Slide 47 Pre and post operative management in tendon transfer Slide 48 Pre and post operative management in tendon transfer Slide 49 Pre and post operative management in tendon transfer Slide 50 Pre and post operative management in tendon transfer Slide 51 Pre and post operative management in tendon transfer Slide 52 Pre and post operative management in tendon transfer Slide 53 Pre and post operative management in tendon transfer Slide 54 Pre and post operative management in tendon transfer Slide 55 Pre and post operative management in tendon transfer Slide 56 Pre and post operative management in tendon transfer Slide 57 Pre and post operative management in tendon transfer Slide 58 Pre and post operative management in tendon transfer Slide 59
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Pre and post operative Physiotherapy management in Tendon Transfer of Hand

Pre and post operative management in tendon transfer

  1. 1. Pre and Post Operative Physiotherapy Management In Tendon Transfer of Hand By Dr. Rajal Sukhiyaji (M.PT. in Sports Science)
  2. 2. Contents • Definition • Principles of tendon transfer • Prerequisites for tendon transfer • Treatment goals • Indications, Contraindications, Precautions • Radial nerve palsy ( Purpose, Preoperative requirements, Tendon transfer, Post operative Management, Different splint) • Ulnar nerve palsy • Median nerve palsy • Post operative complication • Evaluation time • Recent advances • References
  3. 3. Definition :- • Tendon transfer is a surgical procedure that involves moving the insertion of a tendon muscle unit from one location to another location. • A tendon transfer can be used to restore grasp, improve the position of the hand in space, and to prevent deformity, dislocations and contractures.
  4. 4. General Principles Of Tendon Transfer Three important principles should be emphasized 1) The transfer should not significantly decrease the remaining function of the hand. 2) The transfer should not create a deformity if significant return of function occurs following a nerve repair. 3) The transfer should be phasic or capable of phase conservation.
  5. 5. Fundamental principles of muscle- tendon units include the following: 1) Correction of contracture 2) Adequate strength 3) Amplitude of motion 4) Straight line of pull 5) One tendon, one function 6) Synergism 7) Expendable donor 8) Timing of tendon transfer
  6. 6. Prerequisites for tendon transfer • The patient must be a suitable candidate. • All joints must be fully passively mobile. • All skin and soft tissue in the vicinity of the transfer must be pliable and mobile. • The muscle-tendon unit to be transferred must be sufficiently strong to perform its new function in its altered position.
  7. 7. Treatment Goals  Preoperative goals A) Achieving and maintaining full PROM and AROM if possible. B) Achieving maximum strength of the donor muscle and antagonist muscles C) Maintaining supple, soft tissue by minimizing scar, edema, and adhesions and resolving intrinsic/extrinsic muscle tightness. Use gel, elastomer molds, kinesiotape, and so on.
  8. 8. D. Complete comprehensive evaluation, including sensory testing, functional assessments, ROM measurements, strength testing, and photographs for postoperative comparison. E. Educate the patient about the therapy process, splinting demands, and realistic postoperative expectations. F. Establish good communication with the surgeon, schedule postoperative therapy. Review operative report when available.
  9. 9. Postoperative goals A.Protect transferred tendon. B. Maintain ROM of uninvolved joints and involved joints. C. Control postoperative edema and pain. D. Control scar tissue (skin and subcutaneous) and prevent adhesions to decrease drag on transfer. E. Progress patient to functional use of hand.
  10. 10. Indications • Poliomyelitis • Paralysis of muscle • Nerve injury (peripheral or brachial plexus) • Injured (ruptured or avulsed) tendon or muscle • Balancing deformed hand e.g. cerebral palsy or rheumatoid arthritis • Some congenital abnormalities
  11. 11. • Prompt consideration of tendon transfers is indicated if, (a) The prognosis for neurologic recovery is poor even with nerve repair, (b) Muscles have been destroyed, or (c) Nerve grafts have been required to restore nerve continuity.
  12. 12. Contraindications 1. Contracture of joints or skin that would limit movement. 2. Lack of a suitable muscle or muscles for transfer. 3. A progressive neuropathy, e.g. nerve damage following radiation therapy. 4. Complicating medical conditions, e.g. muscle spasm or circulatory inadequacy.
  13. 13. Precaution A. Acceptance of less than full PROM before transfer. B. Overestimation of donor muscle strength C. “Drag” along transfer route secondary to scar D. Technical failures (e.g., rupture of juncture, too loose or too tight) E. Be mindful of stretching out transfer. Wait until 6 weeks after surgery before addressing tightness of transfer.
  14. 14. Radial Nerve Palsy • The classic ‘wrist drop’ result. • When the wrist cannot be stabilized in extension, the power of the long flexors is minimized, thereby seriously impairing grip function. • Where the radial nerve is irreparable, the following functions will need to be restored: 1. Wrist extension. 2. Finger extension (at the MCP joints). 3. Thumb extension and abduction.
  15. 15. Purpose • It is impossible for the patient with this condition to open the hand to grasp objects; therefore, the transfer of normally functioning muscle–tendon units is frequently used to overcome the deficit. • The radial nerve supplies all of the wrist extensors and finger extensors, including the thumb.
  16. 16. Preoperative requirements 1. The wrist must be passively mobile in extension. 2. The MCP joints must be passively mobile in extension. 3. The thumb web space must be normal. 4. There must be a full range of forearm supination/pronation and also elbow flexion/extension. 5. Minimize edema if present.
  17. 17. Tendon transfer for radial nerve palsy 1)Flexor carpi radialis transfer • PT to ECRB for wrist extension • Flexor carpi radialis (FCR) to EDC for finger MP extension • Palmaris longus (PL) rerouted to EPL for thumb extension
  18. 18. 2)Flexor carpi ulnaris transfer • PT to ECRB for wrist extension • FCU to EDC for finger MP extension • PL to rerouted EPL for thumb extension 3)Boyes transfer (Superficialis transfer) • PT to ECRL and ECRB • Flexor Digitorum Superficialis (FDS) III to EDC • FDS IV to Extensor Indicis and EPL • FCR to APL and EPB
  19. 19. Flexor carpi ulnaris (FCU) transfer for radial nerve palsy using pronator teres (PT), FCU and palmaris longus (PL) as motors.
  20. 20. Post operative Management Splint position 1. Elbow in 90 degrees of flexion. 2. Forearm in about 30 to 90 degrees of pronation. 3. Wrist in 30 to 45 degrees of extension. 4. MCP joints in 10 to 15 degrees of flexion; PIP joints free or at 20 to 45 degrees flexion. The splint extends just proximal to the PIP joints which are left free to move. 5. Thumb in maximum extension and abduction.
  21. 21. • Week 0 to week 3 or 4: Splint/cast. A. Maintain ROM of uninvolved joints B. Protective ROM of individual joints C. Avoid composite wrist and digit flexion. D. Edema management E. Scar management F.Desensitization techniques • Week 3 or 4: Splint. Fabricate splint, according to surgeon’s guidance, which may or may not include the elbow. Position the hand and wrist in same positions as in the original cast. A. ROM: as above. B. Scar management
  22. 22. • Weeks 5 to 6: Muscle reeducation. • Week 7: Begin dynamic flexion splinting if extrinsic extensor tendon tightness is present. • Week 8: Discontinue protective daytime splinting; introduce resistive exercises. Begin passive wrist flexion to gain maximum pronator teres length. • Week 12: Resume unrestricted activities.
  23. 23. Different splints
  24. 24. Ulnar Nerve Palsy • Affect pinch and grip strength and manipulation and cause difficulty with the approach of objects due to a claw-hand deformity. • Denervation of the flexor digitorum profundus (FDP) to the ring finger (RF) and small finger (SF) complicates the deficits of intrinsic weakness by further weakening grasp.
  25. 25. • The signs indicative of ulnar nerve palsy are as follows: • Froment’s sign: • Jeanne’s sign:
  26. 26. • Duchenne’s sign: • Wartenburg’s sign:
  27. 27. • Purpose ▫ Restore balance and function of a hand ▫ This may occur as a result of prolonged compression as in cubital tunnel syndrome, trauma, disease, infectious processes, congenital anomalies, or spastic paralysis. • Where the Ulnar nerve is irreparable, the following functions will need to be restored: 1) MCP joints Flexion 2) Thumb adduction.
  28. 28. • Preoperative requirements for ulnar nerve lesion 1. The PIP joints must be fully mobile in passive extension and the MCP joints fully mobile in passive flexion. 2. Soft tissues should be free of contracting scar and have adequate circulation.
  29. 29. Tendon Transfer for Ulnar nerve palsy o Suitable muscle-tendon units include: • Flexor digitorum superficialis, extensor carpi radialis longus, extensor carpi radialis brevis, flexor carpi radialis, brachioradialis and palmaris longus. • The smaller extensors, i.e. extensor indicis proprius and extensor digiti minimi (quinti) can provide intrinsic function with the transfer of a muscle to two fingers each (original Fowler technique)
  30. 30. • Superficialis transfers are designed to integrate MCP joint and IP joint motion. They do not, result in increased grip strength . The use of a wrist extensor to flex the MCP joints will improve gross power grip.
  31. 31. • Low Ulnar Nerve Injury A) Intrinsic Rebalancing 1) FDS of middle finger (MF)
  32. 32. 2) Zancolli lasso procedure 3) Brand transfer of ECRL/ECRB to intrinsics with tendon graft B) Restoration of power pinch 1) Smith-Hastings procedure ECRB  ADP with graft 2) FDS of RF  ADP • High Ulnar Nerve Injury 1) ECRL  FDP
  33. 33. Post operative management • Splint position 1. Wrist in 45 degrees of extension. 2. MCP joints in 70 degrees of flexion. 3. IP joints in full extension. 4. The thumb remains free
  34. 34. Postoperative day 10 to 14: • Remove postoperative cast, have tension checked by surgeon, and immobilize patient in splint or recast. ▫ A. Fit the patient with a splint ▫ B. Gentle AROM and PROM within the restraints of the splint. Week 4: • The hand and forearm are maintained in the described position for the first postoperative month. • Begin AROM out of splint, avoiding composite extension.
  35. 35. Week 6: • When the hand is removed from the splint and placed on the table, there will be a slight relaxation of the positions of wrist extension and MCP joint flexion. • The patient is then asked to actively extend the wrist which should result in some MCP joint flexion. Extension of the IP joints should be maintained during this manoeuvre. • The hand is returned to the splint after each exercise session until the end of the 6th week.
  36. 36. • The patient should perform this exercise on a 1 to 2 hourly basis with 5 to 10 repetitions during the 1st week of active exercise. • By the 2nd week, the patient learns to localize the action of MCP joint flexion without having to extend the wrist and practises the movement with the hand in all positions, i.e. palm up and with the hand on the side. • By the 5th week, emphasis is placed on active flexion and extension of the fingers while maintaining MCP joint flexion. Gentle active wrist flexion is also begun. May introduce light resistance.
  37. 37. Week 6 to 12: • Progressive resistive exercises. It is important not to fatigue the transfer. • Light gripping activities are commenced. • Graded resistance is applied to MCP joint flexion with the IP joints extended, i.e. intrinsic flexion. • The activity programme is upgraded to restore maximum power grip.
  38. 38. Different splints
  39. 39. Median nerve Palsy • Functional impairment from a median nerve lesion is primarily the result of lost skin sensibility on the working surfaces of the thumb, index and middle finger, those used for precision manipulation, rather than the loss of muscle function. • The main function that needs to be replaced is opposition of the thumb. • Three muscles are used for this function ▫ Abductor pollicis brevis, ▫ Opponens pollicis and ▫ Flexor pollicis brevis.
  40. 40. Purpose • Restore balance and function of a hand. • This may occur through prolonged compression as in carpal tunnel syndrome, trauma, disease, infectious process, congenital anomalies, or spastic paralysis.
  41. 41. • Preoperative Requirements prior to opponensplasty for low level lesion (wrist) 1. Normal or maximal thumb web span. 2. Mobile thumb joints. 3. Full mobility of the unaffected digits. 4. Soft tissues should be free of contracting scar and have adequate circulation.
  42. 42. Tendon transfer for Median nerve Low Median nerve palsy • Opponensplasty :- A. FDS of ring finger (RF) or PL to APB : long opponens splint
  43. 43. B. Extensor indicis proprius (EIP) to APB: long opponens splint
  44. 44. C. Abductor digiti minimi (ADM) to APB : hand-based or long opponens
  45. 45. Post operative Management • Splint position • The wrist is immobilized in neutral extension with the thumb held in full opposition and the IP joint of the thumb held in extension • The fingers are left free to move. • If the PIP joint has been tenodesed to prevent hyperextension deformity, it should be splinted in about 45 degrees of flexion during the immobilization period.
  46. 46. Postoperative day 10 to 14: Remove postoperative cast, have tension checked by surgeon, and immobilize patient in splint. Address wound care, edema reduction, and scar management if indicated. Week 3: Begin AROM of thumb in splint to activate transfer, six to eight times per day Week 4: Begin AROM of thumb and other joints out of splint. Focus on activation of transfer. May use light grasp and prehension tasks.
  47. 47. Week 6: Discharge splint for protection and begin unrestricted AROM/PROM. May introduce light resistance. Week 8: Progressive resistive exercises. Preferably the patient should complete frequent low-resistance exercise sessions rather than occasional higher-resistive exercises. It is important not to fatigue the transfer. Week 12: Resume unrestricted activities.
  48. 48. High Median Nerve Injury • Flexor Pollicis Longus • Brachioradialis/FDS to FPL: dorsal blocking splint (possibly long arm splint with elbow in 90 degrees flexion for brachioradialis)
  49. 49. Postoperative day 10 to 14: Week 3: AROM of MCP/IP within splint to activate transfer, six to eight times per day9 Week 4: AROM out of splint for transfer activation and light prehension Week 6: Discharge splint; PROM and splinting to decrease tightness if present Weeks 7 to 8: Progressive resistive exercises
  50. 50. Different splint
  51. 51. Post operative Complication • Scarring of tendon to surrounding structures • Difficulty activating transfer. • Transfer too loose or too tight. Wait 6 weeks before doing any PROM or splinting against transfer. • Rupture of transfer repairs • Overstretching of transferred tendon
  52. 52. Evaluation Timeline Postoperative day 10 to 14 (after tension has been checked by surgeon) A. Control of edema and pain, wound care B. ROM of uninvolved joints and protected ROM of involved joints as allowed C. Splint for protection and immobilization Week 3: AROM of joints and activation of tendon transfer in splint
  53. 53.  Week 4: AROM of all joints with splint removed; nonresistive activities in therapy, NMES for transfer activation Weeks 6 to 8: Discharge protective splint. AROM/PROM and functional activities, splinting for tightness. Progressive resistive exercises at week 8. Week 10: Manual muscle testing and functional outcomes
  54. 54. Recent advances • Flexor digitorum superficialis opposition tendon transfer improves hand function in children with Charcot-Marie- Tooth disease: Case series, December,2013 • Transfer of the flexor digitorum superficialis tendons of the middle and ring fingers to restore extension of fingers and thumb (Boyes' transfer), August,2013
  55. 55. References • Burke, Higgins, McClinton, Saunders, Valdata. Hand and Upper Extremity Rehabilitation, A Practical Guide, 3rd Edition. • Judith Boscheinen-Morrin. The hand: fundamentals of therapy – 3rd Edition • Robert w. Beasley, Tendon Transfers, Ch.-88
  56. 56. • Cynthia Cooper, Fundamentals of hand therapy, Clinical Reasoning and Treatment Guidelines for common diagnosis of Upper Extremity • Dr Jason Crane, Tendon transfers for nerve injuries of the Upper Limb • GS Kulkarni, Textbook of Orthopedics and Truma, Volume One.
  57. 57. • Flexor digitorum superficialis opposition tendon transfer improves hand function in children with Charcot-Marie- Tooth disease: Case series. T. Estilow; S.H. Kozin; A.M. Glanzman; J. Burns; R.S. Finkel, January, 2014. • Transfer of the flexor digitorum superficialis tendons of the middle and ring fingers to restore extension of fingers and thumb (Boyes' transfer). Pillukat T; Blanarsch B; Schädel-Höpfner M; Windolf J; van Schoonhoven J; August, 2013.
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Pre and post operative Physiotherapy management in Tendon Transfer of Hand

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